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A 49 year old man was referred to the cardiology clinic for a loud systolic murmur. He was an ex-smoker and had a past history of thyrotoxicosis for which he had radioactive iodine treatment followed by current oral thyroxine replacement. His co-morbid problems included hypertension and hyperlipidaemia. He complained of having retrosternal chest discomfort for two years with a recent onset of exertional dyspnoea over two months. In addition, he also had loss of appetite as well as weight loss over the past one year. On examination, he was clinically euthyroid. There was a loud and harsh ejection systolic murmur loudest over the left lower sternal edge with no radiation of the murmur.

A two dimensional echocardiogram was performed. This revealed a large mass lesion adjacent to the right ventricle (panel A: Ao, aorta; LA, left atrium; LV, left ventricle; RV, right ventricle). Colour flow imaging demonstrated a mosaic pattern consistent with that of a turbulent flow across the right ventricular outflow tract (panels B and C: AVO, aortic valve orifice; PV, pulmonary valve; RVOT, right ventricular outflow tract). The peak Doppler gradient across the right ventricular outflow tract was 24 mm Hg (panel D).

A computed tomogram (CT) of the thorax was performed on the same day. This showed a heterogenous anterior mediastinal mass measuring approximately 8 × 6 cm which was invading the pericardium inferiorly (panels E and F). The mass was distorting the superior portion of the right ventricle. It was also displacing the pulmonary trunk posteriorly. Several lobulated hypodensities were seen in the right hepatic lobe and the caudate lobe which were suggestive of hepatic metastases. The patient then underwent a CT guided biopsy of this anterior mediastinal mass. The histopathology of this mass was consistent with that of a thymic carcinoma. He was referred to the oncologist and chemotherapy was planned as the modality of treatment for his condition.

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